From report to drill: How firefighters can train with NIOSH investigations

By Bill Carey and Wesley R. Attwood

Behind every National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program report is a firefighter, a family and a department that experienced an event no fire department wants to repeat. This can make reports difficult to read, but they provide other departments an opportunity to learn from an incident rather than experiencing it firsthand.

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The reports are not enforcement documents and are not intended to assign blame. Their value lies in showing how an incident unfolded, how conditions changed, and which factors influenced the outcome.

For training and company officers, each report can serve as a ready-made case study.

Access the reports

Completed NIOSH investigations are posted on the NIOSH website. Trauma reports are accompanied by slides that summarize the report’s content. All NIOSH reports and publications are in the public domain and may be freely distributed for training and educational purposes.

Start with the incident, not the prevention actions

Start training with the incident narrative, not the prevention actions. Have members reconstruct the call, identify key conditions and decisions, then pause the scenario just before a critical choice.

Ask, “What would we do next?” Have members make the decision using only the information available at that point, then compare their choices with the investigation findings.

Turn contributing factors into training objectives

NIOSH investigations identify factors that may have contributed to a death or serious injury and recommend ways to prevent similar incidents. Those contributing factors can then become training objectives for departments. Some commonly repeated contributing factors are:

• Initial and ongoing scene size-up
• Crew integrity and accountability
• Radio communications
• Air management
• Mayday recognition and transmission

The goal isn’t to recreate every detail, but to identify the transferable problem. Ask: “Could this happen here?”

Build a kitchen-table drill

One simple drill approach is a short company-level discussion. Choose a relevant report, share the initial dispatch and arrival conditions without revealing the outcome, then work through three questions:

1. What are you seeing? Have members identify the hazards, building factors, fire conditions, staffing issues, and operational concerns.
2. What are you doing? Require specific answers such as strategy, initial assignments, hoseline placement, search priorities, ventilation considerations, command structure and accountability.
3. What would make you change your plan? Identify the conditions or benchmarks that should cause crews or command to change tactics, withdraw, or declare a Mayday.

Reveal what happened and review the NIOSH findings and recommendations. The report slides can be used to discuss and illustrate these. Ask “What should we do differently?”

Take the report to the training ground

Turn report findings into hands-on training. Practice Mayday communications under stress, test accountability systems, simulate firefighter disorientation or use tabletop scenarios that force incident commanders to respond to deteriorating conditions. One report can easily support several separate training sessions.

Example: NIOSH Report F2024-06 examines a firefighter fatality and firefighter injury during rapid intervention team operations at a vacant warehouse fire in Texas. Recommendations included pre-incident planning for dangerous or vacant structures, maintaining SOPs or SOGs, matching tactics to incident conditions, training personnel in risk-management principles, and strategically deploying safety officers.

Apply the report to your first due

Discuss the report findings using your jurisdiction and structures. Ask “How would we address the same incident and conditions?” while out with crews during pre-planning, fire inspections, or even a fuel run. Stop at structures and apply the report findings through discussion of strategy and tactics.

Use reports to test your SOPs

Compare the report’s circumstances with your SOPs or SOGs. Ask whether policies are clear, crews have trained on them, staffing supports them and accountability, and strategy changes can hold up under pressure.

NIOSH’s review of 282 investigation reports from 2006 through 2014 found that training, SOPs/SOGs, and incident command were the three leading areas associated with traumatic firefighter fatalities.

Keep blame out of the discussions

When using reports for training, avoid Monday-morning quarterbacking. Firefighters were operating under stress, with limited information and changing conditions. Like NIOSH investigations, training should focus on lessons learned, not assigning blame

Instead of asking, “Why did they do that?” ask: “What conditions could lead one of us to make the same decision?”

Add the reports to your training calendar

A company officer could conduct one NIOSH-based tabletop scenario each quarter. A training division could select reports connected to the year’s training priorities. Battalion chiefs could use reports during officer development. Departments could assign reports before live-fire, Mayday, RIT, driver, or command training so members understand the real-world events behind the skills they are practicing.

Make NIOSH report reviews routine

Departments can make NIOSH reports part of routine training through quarterly tabletop scenarios, Mayday or RIT drills, command training, officer development, and SOP reviews. A simple place to start is with five questions:

1. What happened?
2. What factors contributed to the outcome?
3. Could those factors exist in our department?
4. What do our SOPs and training say we should do?
5. What can we practice or change before the next incident?
6. What went right that prevented the outcome from being worse?

The value of a NIOSH investigation goes beyond understanding what happened. It is about recognizing contributing factors and applying those lessons before they happen in your department.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.

How does your department use NIOSH reports in training? Tell us how you work them in, or which report changed how your crews operate.

ABOUT THE AUTHORS
Wesley R. Attwood, DrCJ, is the Senior Investigator with the NIOSH Fire Fighter Fatality Investigation and Prevention Program’s Trauma team.